Pleuroscopic Pleurodesis Combined With Tunneled Pleural Catheter for Management of Malignant Pleural Effusion: A Prospective Observational Study.

BACKGROUND: Malignant pleural effusion (MPE) is associated with poor prognosis and it often impinges upon quality of life; effective and efficient management is desirable. Combining pleuroscopic pleurodesis (PP) with a tunneled pleural catheter (TPC) could minimize hospitalization, effect rapid pleurodesis in most cases, and allow ongoing control of MPE for those not successfully pleurodesed. METHODS: Consecutive patients with pleural effusion associated with malignancy and with documented lung reexpansion after pleural fluid drainage were prospectively enrolled to undergo PP with TPC placement. TPC was drained daily and was removed when output was <50 mL/d. Patients were followed for up to 6 months. The data collected were compared with historical controls as provided by a previously published study by our group on conventional pleuroscopic pleurodesis (CPP). RESULTS: Thirty patients were enrolled between January 2012 and August 2013. Twenty-nine completed the protocol. Pleurodesis was successful in 92% of patients at 1 month. Of the patients alive at 6 months, 96% continued to have effective pleurodesis. The median duration of TPC placement was 6 days. The median LOS was 3 days (2 to 7.25). All patients experienced significant improvement in dyspnea scores. The median LOS was significantly lower than those who received CPP (median LOS, 9 d; range, 4 to 13 d; P=0.002). There was no significant difference in mortality rates and pleurodesis success rates. CONCLUSIONS: The combination of PP with TPC can effect pleurodesis at a rate similar to CPP, shortens LOS, shortens time to pleurodesis, and helps to control symptoms when pleurodesis fails.

The fallacy of the BUN:creatinine ratio in critically ill patients.

BACKGROUND AND OBJECTIVES: Acute kidney injury (AKI) is common in critically ill patients and is associated with a high mortality rate. Pre-renal azotemia, suggested by a high blood urea nitrogen to serum creatinine (BUN:Cr) ratio (BCR), has traditionally been associated with a better prognosis than other forms of AKI. Whether this pertains to critically ill patients is unknown. METHODS: We conducted a retrospective observational study of two cohorts of critically ill patients admitted to a single center: a derivation cohort, in which AKI was diagnosed, and a larger validation cohort. We analyzed associations between BCR and clinical outcomes: mortality and renal replacement therapy (RRT). RESULTS: Patients in the derivation cohort (N = 1010) with BCR >20 were older, predominantly female and white, and more severely ill. A BCR >20 was significantly associated with increased mortality and a lower likelihood of RRT in all patients, patients with AKI and patients at risk for AKI. Patients in the validation cohort (N = 10 228) with a BCR >20 were older, predominantly female and white, and more severely ill. A BCR >20 was associated with increased mortality and a lower likelihood of RRT in all patients and in those at risk for AKI, BUN correlated with age and severity of illness. CONCLUSIONS: A BCR >20 is associated with increased mortality in critically ill patients. It is also associated with a lower likelihood of RRT, perhaps because of misinterpretation of the BCR. Clinicians should not use a BCR >20 to classify AKI in critically ill patients.